More Related Content Similar to Jgk noon conference 5.7.19 (20) More from Virginia Mason Internal Medicine Residency (20) 2. © 2016 Virginia Mason Medical Center 2
Objectives
Bioethics Case
• Review clinical case
• Present clinical challenges
• Group discussion/brainstorming
• Case outcomes
• Bioethics review
3. © 2016 Virginia Mason Medical Center
Background
• 68 yo F w/ hx of metastatic lung adenocarcinoma
• Metastases to the bone and CNS
• S/p radiation & 2nd round of chemotherapy with
carboplatin/pemetrexed/pembrolizumab
• Recently admitted to the hospital for 8 days (1 week
prior to this admission)
• Nausea, vomiting, anorexia, failure to thrive
• Marginal improvement after increased dexamethasone,
dronabinol, megestrol and THC candies
• Decision not to proceed with tube feeds
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On Admission
• CC: 4 days of dry cough progressing to wet cough
as well as fatigue
• Vitals: 37.1, 104/80, 104, 18, 94% RA
• PE: RLL crackles, normal WOB, RRR, no m/r/g, 4/5
strength throughout
• Labs:
• CBC: WBC 1.9 (5% bands), Hgb 11, Plt 36; BMR: WNL
• Influenza A positive
• CXR:
• Patchy airspace opacities in medial RLL suspicious for
pneumonia or possibly aspiration
• Stable known left lower lung mass
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Diagnosis
• Patient was diagnosed with pneumonia and
influenza A
• Was started on Tamiflu for 10 day course
• Was started on Vancomycin, Zosyn &
Azithromycin for PNA in an
immunocomprimised patient
• MRSA nares were negative & vancomycin was dc’d
• Patient completed a 7 day course of abx after
normalization of WBC and undetectable procalcitonin
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6. © 2016 Virginia Mason Medical Center
Clinical Course
• Day 1: progressive severe hypotension with SBP’s frequently in
the 70-80’s (not particularly symptomatic)
• Requiring frequent 500cc boluses
• Day 3: patient developed encephalopathy
• MRI showed possible infarcts but ultimately ruled out per neurology
• Improved after resolution of pneumonia and influenza
• Day 5: CT chest showed improving multifocal pna, suspicion for
lymphangitic carcinomatosis, multiple new osseous metastases
& enlarging hepatic metastases
• Day 6: patient developed severe hypokalemia in the setting of
severe malnutrition due to progressive dysphagia
• Recurrent throughout hospitalization requiring frequent IV repletion
• Numerous daily discussions with palliative care, heme/onc,
medicine team with patient & family regarding goals of care
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Clinical Course
• Day 11: code status changed to DNR/DNI
• Day 16: family meeting
• Pt/family feel optimistic patient has improved in functional status post
flu/PNA & desire aggressive therapy to prolong life as long as possible
• Day 18: family meeting
• Similar discussion to prior
• Added midodrine to help with BP
• Patient taking progressively less & less PO
• Requiring escalating frequency of fluid boluses
• More & more difficulty working with PT & OT
• Day 24: psych consult – pt does not have decisional capacity,
trialed dextroamphetamine to help increase energy level
• Day 24: family meeting
• Pt distressed about son’s situation in jail & distraught when told that
her body is getting weaker
• Day 24: ethics consult
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Challenges
• Frequent visits with palliative care and difficulty for family
and patient to come to terms with clinical status
• Son in prison & the families guilt surrounding their
perceived unjust imprisonment
• Desire to have their family reunited before the patient passed
away – often the unspoken context behind their decision-making
• Desire to keep trying to get stronger & to be able to walk
• Patient’s lack of decisional capacity/inability to fully
understand
• Patient’s perseverations and clear dissent when
attempting to move to comfort care approach
• Family’s inability to care for the patient at home/desire to
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Discussion Questions
• How should clinicians manage a terminally ill
patient's medical treatments when the goals are
unclear and the patient can only survive in the
hospital environment?
• How do you balance shared decision making with
offering what is considered medically appropriate
treatment?
• How do you incorporate patient perspectives
when they lack decisional capacity?
• How can you help patient’s and families cope
with moral distress when it is impacting their
ability to participate in medical decision making?
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Case Outcomes
• Recommendations from bioethics
• 1 week time trial – full aggressive approach for 1 week with clear
tangible outcomes:
• Including PO intake, ability to walk, ability to maintain electrolytes
• Positive encouragement for the patient, spiritual care consult
• Day 28: new hypoxia & chest pressure
• CT: PNA vs. edema, no lymphangitic spread of cancer
• Pulm consult: started solumedrol, vanc & zosyn
• Echo: no volume overload, normal LVEF
• Day 31: R sided facial droop, slurred speech w/ rapid resolution
• CT head: unrevealing
• Day 32: family meeting
• Patient still distraught when transition to comfort care discussed
• Husband (DPOA) implying subtly that he would be ok with this transition
• Decision made to complete course of steroids & antibiotics and then
make the transition
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Case Outcomes
• Day 34: SW coordinating a deathbed visit with son from
prison
• Decision made to continue IVF and electrolytes until this visit
• Day 37: son visits from prison
• Afterwards – comfort care transition is made
• Informed assent/non-dissent from the patient’s husband supported
this decision
• Day 38-51: increasing pain – PCA ultimately started
• Ongoing coordination with SW for placement
• Day 52: patient discharged to SNF for hospice
• Shortly after discharge patient passed away on hospice
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Bioethics Review
• Classification of Treatment:
• Medically Appropriate
• Aligns with pt GOC & that a prudent physician would
provide based on generally accepted standards
• Potentially inappropriate
• At least some chance of accomplishing pt goals but
physicians believe may not be ethically justified
• Not medically appropriate
• The opposite of medically appropriate
• Medically futile
• Despite the intervention the patient will die in the
very near future
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Bioethics Review
• Clinicians do not have an ethical obligation to initiate
or that is medically futile or not medically
appropriate
• Physicians should use informed assent or non-
dissent
• This does not require specific agreement
• Rather recommendations given in a statement from
clinicians
• If there is strong disagreement, clinical ethics should be
involved to help resolve this challenge
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14. © 2016 Virginia Mason Medical Center
VM Conflict Resolution Process for Shared
Decisions for Life-Sustaining Treatment
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Conflict Resolution Processes for
Shared Decisions for Life-Sustaining Treatment
Request Clinical Ethics Consultation
Involve EMD and/or CNO/RN Director
Patient's
has Capacity?
If Goals of Care are unclear,
involve Palliative Care
Huddle with all
treating clinicians
Align the Plan of
Care to respect
the Patient's
wishes.
Yes No
Inform patient and surrogate of process
Conduct
Time-Trial
If Time-trial fails or no-change,
use assent/non-dissent
Outside 2nd Opinion
Clinical Ethics Subcommittee Review
Get VM 2nd
Opinion
Final resolution is the responsibility
of the Attending and EMD/ACO
Conflict
continues
Conflict
continues
Conflict remains
Conflict
continues
Patient/Surrogate
Assents
And
Disagreement is between:
Follow
orange lines Follow
blue lines
Follow
green lines
Clinicians
Treatment
Status
Already started
or offerred
Clinicians Patient/
Surrogate
Patient Surrogate(s)
Not started or
recommended
Conflict remains
Care Conference
and consider CEC
recommendations
Get VM 2nd
Opinion
Conflict
continues
EMD = Exective Med. Director
ACO = Admin. On-call
© Virginia Mason Medical Center
16. © 2016 Virginia Mason Medical Center
References
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• Varcoe, C., Pauly, B., Webster, G., & Storch, J. (2012). Moral distress: tensions as springboards for action.
HEC Forum, 24(1), 51-62. doi: 10.1007/s10730-012-9180-2, Pg. 59
• Statement of the American Medical Association Institute of Medicine’s Committee on Determination of
Essential Health Benefits, 2011
• Gabriel T. Bosslet, Thaddeus M. Pope, Gordon D. Rubenfeld, Bernard Lo, Robert D. Truog, Cynda H.
Rushton, J. Randall Curtis, Dee W. Ford, Molly Osborne, Cheryl Misak, David H. Au, Elie Azoulay, Baruch
Brody, Brenda G. Fahy, Jesse B. Hall, Jozef Kesecioglu, Alexander A. Kon, Kathleen O. Lindell, and Douglas
B. White An Official ATS/AACN/ACCP/ESICM/SCCM. Policy Statement: Responding to Requests for
Potentially Inappropriate Treatments in Intensive Care Units American Journal of Respiratory and Critical
Care Medicine 2015 191:11, 1318-1330
• Kon AA, Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M. F., Birriel, B., & Rincon, F. (2016).
Defining futile and potentially inappropriate interventions: A policy statement from the Society of Critical
Care Medicine Ethics Committee. Critical Care Medicine, 44(9), 1769-1774. doi:
10.1097/CCM.0000000000001965
• Brody, BA & Halevy, A. Is futility a Futile Concept? The Journal of medicine and Philosophy 20: 123-144,
1995
• Schneiderman, LJ & Jecker, NS. The Abuse of Futility. Perspectives in Biology and Medicine 60;3 295-313,
2017
• Curtis JR, Burt RA. Point: the ethics of unilateral "do not resuscitate" orders: the role of "informed assent".
Chest. Vol 132. United States2007:748-751; discussion 755-746.
• Kon AA. Informed non-dissent: a better option than slow codes when families cannot bear to say; let her
die. Am J Bioeth. 2011;11(11):22-2
Editor's Notes Hospital course up until the ethics consult was placed If a patient lacks capacity should we still take dissent in the same way? Why or why not?
Authentic statements – consistent and persistent statements
Lack of consistent authentic statements
Respect for persons
Shared decision making
It is important to take account reversibility of a disease
Treatments should be weighed by patients underlying comorbidities
Patients must be able to appreciate the benefit and survive
And the treatments must allow them to sustain outside the walls of the hospital
Medically Appropriate or Medically Necessary: a medically necessary treatment or intervention that aligns with a patient's Goals of Care and "that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician or other health care provider."
Not Medically Appropriate Treatment: The opposite of Medically Appropriate/Necessary treatment. Specifically, it is an intervention that meets one or more of the following:
It does not meet a patient's Goals of Care,
It does not align clinically with the patient's treatment plan according to the standards of care,
It is not clinically appropriate or indicated based on the illness, injury or disease present,
Futile is very narrow and limited – most narrow definition – physiologic futility?
VM protocol- kept narrow definition that is shared by community, UW, evergreen… an intervention is futile if even if it is used the pt will die from the underlying dz in an imminent fashion – ex: CHF, renal failure, 3 vasoactive meds and BP still dropping, can’t maintain BP even if 3 meds, the vasoactive meds are futile bc pt is dying regardless of this
Important to see evidence of that before labelling it as futile.
In our case:
Patient did ok after withdrawal of these therapies
Up until the time trial the treatments were potentially inappropriate
After the decompensation, clear that it was not medically appropriate
Ultimately by using our time trial approach, we were able to clarify our goals and help the family work towards understanding that treatment was medically inappropriate as the patient continued to clinically deteriorate
